Saturday, July 13, 2013

As we have noted previously, colorectal
cancer is a leading preventable cause of cancer mortality. See related posts. Screening can be
effective reducing deaths by half. Yet it is underutilized. Multi-level
interventions addressing system changes and individual factors can effectively
increasing screening. To date, most interventions have been implemented and
evaluated in higher-resource settings such as health maintenance organizations.
Given the disparities evident for
colorectal cancer and the potential for screening to improve outcomes, we describe
our ongoing NCI funded research that is expanding the population included in
such studies. We recently published the protocol for our ongoing study that includes economically disadvantaged patients. (see report online). We describe the study protocol for a trial designed to increase colorectal
cancer screening in those 'safety-net' health centers that serve underinsured
and uninsured patients in Missouri. This trial was designed and is being
implemented using a community-based participatory approach.

What was our approach?

We developed a practical clinical
cluster-randomized controlled trial. We are currently recruiting 16 community
health centers to participate and collaborate in this trial. This systems-level
intervention consists of a menu of evidence-based implementation strategies for
increasing colorectal cancer screening. Health centers in the intervention arm
then collaborate with our Siteman and Washington University based study team to tailor strategies to their own
setting to maximize fit and acceptability. Data are collected at the
organizational level through interviews, and at the provider and patient levels
through surveys. Patients complete a survey about their healthcare and
screening utilization at baseline, six months, and twelve months.

How will we assess success in brining screening to our underserved communities?

The primary outcome for our study is
colorectal cancer screening that we record through patient self-report. We will
supplement these self –reports with a chart-audit in a subsample of patients. This
is similar to the approach we used in a primacy care based intervention in New England
that showed success in creasing screening rates more than a decade ago (see report). Implementation outcomes informed by the Reach,
Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM)
conceptual framework will be measured at the patient, provider, and practice
levels. This approach has been used previously to evaluate interventions in low-income settings and assess the overall public health benefit.

Why is this study important?

Our study is one of the first to
integrate community participatory strategies to a randomized controlled trial
in a low-income healthcare setting. The multi-level approach will support the
ability of the intervention to affect screening through multiple avenues. The
participatory approach will strengthen the chance that implementation
strategies will be maintained after study completion and, supports external
validity by increasing health center interest and willingness to participate.